Mandrola Previews the Virtual ESC 2020

Months into the pandemic, I get the necessity of virtual meetings. Yet understanding it does not make it any less sad. A huge part of meetings is seeing friends and colleagues.

I will especially miss this year’s European Society of Cardiology (ESC) Congress, which was slated for Amsterdam. The last time ESC was in the Dutch capital, I commuted to and from the congress by bike. For an American, the experience was thrilling.

It also led to a life-changing moment.  A slight drizzle complicated one of our morning commutes. At a stoplight, I asked a young Dutch cyclist what he did when it really rains. He looked puzzled at the question: “We wear a jacket” Since that day, I have ridden my bike to work in all weather.  



ESC in 2020 may be virtual, but there will be serious science.

More on SGLT2 Inhibitors in Heart Failure

The results of the second randomized controlled trial (RCT) of sodium/glucose cotransporter 2 (SGLT2) inhibitors in patients who have heart failure with reduced ejection fraction (HFrEF) leads off the Hot Lines sessions. We know from a press release that the EMPEROR-Reduced trial comparing empagliflozin vs placebo met its primary endpoint: a composite of cardiovascular (CV) death or heart failure hospitalization.

Two comments: Not long ago the SGLT2 inhibitor benefit in  patients who don’t have diabetes surprised people. At least in my zip code, uptake of these drugs has been slow. Having two favorable trials will likely speed acceptance. The second thing to look for in the trial presentation is the magnitude of benefit. In DAPA-HF, dapagliflozin reduced this composite by 26% in relative terms but nearly 5% in absolute terms. Will empagliflozin look this good? HFrEF is a big market.

ESC will also feature another clinically relevant trial of SGLT2 inhibitors. The placebo-controlled DAPA-CKD trial (n ≈ 4000) will test whether dapagliflozin preserves kidney function in patients with chronic kidney disease (estimated glomerular filtration rate ≥25 and ≤75 mL/min/1.73 m2). Although this is not a pure cardiac trial, if the results are positive they will add momentum.

It could be a big week for this class of drugs.

AF Care

One of the toughest questions in all of electrophysiology is the timing of rhythm control strategies in patients with atrial fibrillation (AF). I’ve seen patients present with flurries of AF episodes that calm down spontaneously over the coming weeks. Heck, my AF was like that. If an ablation was done early in the course, the procedure would have been mistakenly credited for resolving the AF.

On the other hand, it’s possible that early rhythm control could preserve atrial structure and function and promote sinus rhythm. Yet rhythm control does not come free—drug side effects and procedural complications reduce its net clinical benefit.
You know the best way to sort this out: Say it with me, R…C…T… .

The EAST trial will randomly assign patients to usual care or early rhythm control. Rhythm control could be catheter ablation or antiarrhythmic drug therapy. The trial will enroll approximately 3000 patients and measure two co-primary endpoints: one a composite of cardiovascular death, stroke, worsening of heart failure, and myocardial infarction, and the other, nights spent in the hospital. This is a pragmatic trial, and interpretation could be complicated. That said, we need a modern-day replication of the AFFIRM trial, which shocked the world of cardiology when it found no survival benefit for rhythm control in older patients with AF.

Novel Therapies

Two drugs I had not heard of will be tested in important cardiac conditions.

Mavacamten (or MYK-461) modulates cardiac myosin; it may improve left ventricular compliance and reduce hypercontractility and left ventricular hypertrophy. These actions could benefit patients with symptomatic obstructive hypertrophic cardiomyopathy. Phase 2 trials offered hope.  On the first day of ESC, we will hear the results of EXPLORER-HCM , an industry-sponsored RCT testing the novel drug against a placebo. The primary endpoint is the percentage of patients who achieve a positive response in symptoms and exercise capacity.

Trimetazidine is a metabolic agent that may mitigate the effects of ischemia. The idea is that by countering the effects of calcium overload and the production of free radicals, the drug may limit areas of necrosis and promote return of cardiac function after ischemia is stopped. The ATPCI trial will test whether this old drug will reduce cardiac death, hospital admission for a cardiac event, and recurrence or persistence of angina in patients who have had percutaneous coronary intervention for stable or unstable coronary heart disease.

Pragmatic Trials for Common Cardiology Problems

Hot Lines sessions will include RCTs that test sacubitril/valsartan vs an individualized approach to the use of renin-angiotensin-aldosterone system blockers in patients with heart failure with a preserved ejection fraction, colchicine for the primary prevention of cardiac events, and the safety of clopidogrel alone vs clopidogrel plus aspirin after transaortic valve replacement. My structural partners call antithrombotic therapy after transcatheter aortic valve replacement an evidence-free zone, so the latter trial will be welcome. These studies may not move the stock market, but they will inform everyday clinical practice.
 

Guideline News

The ESC will update its guidelines for AF, non-ST-segment acute coronary syndrome, sports cardiology, and congenital heart disease. Guideline changes can be a challenge. The good news is that thanks to the excellent reporting of theheart.org | Medscape Cardiology journalists, you can quickly learn what is new. Pro tip: After you learn what is new, go look at the text of the guideline document rather than just the summary boxes. The text tells you how the writers came to their decision.

COVID-19

A medical meeting in 2020 without a focus on coronavirus would seem unusual. BRACE-CORONA is an RCT comparing continuing vs suspending angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with COVID-19. There will also be numerous lectures on different aspects of the virus.

Young Investigators

One of my premeeting habits has been to review the awards for young investigators. The link to the page is here; two studies caught my eye.

Anders Holt, from Copenhagen, will present a study that used Danish registries to examine the effect of β-blockers after myocardial infarction in the modern era. Trials that reported improved outcomes from post-myocardial infarction β-blockers were done decades ago, before the reperfusion era. Whether these drugs help now is an important question.

As a believer in the utility of basic 12-lead electrocardiography, I was drawn to a study from Jose R. Medina-Inojosa, from the Mayo Clinic, looking at the association of artificial intelligence (AI)–enabled electrocardiography-derived age (physiologic age) with atherosclerotic cardiovascular events in the community. I am hopeful that AI can extract even more information from this painless, inexpensive test.

Virtual Browsing

The ESC meeting site will offer live session, on-demand presentations, and 10 channels for browsing—each seeming to simulate the villages of the in-person meeting. The digital ESC experience looks to be free, but you have to pre-register.

No doubt there will be much more than I have previewed. Our  team at theheart.org | Medscape Cardiology will be virtually covering the meeting. They are true professionals.

Stay tuned. Follow us on Twitter and Facebook. Meeting hashtag: #ESCCongress

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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